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Peter Beresford · Prevention of Future Deaths report View report

12 Mar 2024 Manchester South L. Costello

Peter Beresford contacted the North West Ambulance Service with chest pain on 25 September 2023 and was found deceased when an ambulance arrived at his home. The report raised concerns that delays in attending Category 2 calls persisted because of staff and emergency vehicle shortages, and that ambulance resources could not be fully utilised because of delays clearing Accident and Emergency departments.

David John Briggs · Prevention of Future Deaths report View report

1 Dec 2023 South Yorkshire (Western) H. Berry

David John Briggs died at the Northern General Hospital, Sheffield, on 15 November 2022 after developing urosepsis associated with urinary tract obstruction and a long-term catheter. His carers made several emergency calls as his breathing deteriorated, but the ambulance arrived at 0044 after the first call at 2049. Concerns included insufficient ambulance service resources, delays in responding to the Category 2 call, and hospital offloading delays that reduced ambulance availability.

Jean WALKER · Prevention of Future Deaths report View report

20 Mar 2024 South Yorkshire (Western) H. Berry

Jean WALKER became unwell at home on 4 November 2022 and was struggling to breathe when her daughter called 999 at 0348. She died before the ambulance arrived at 0542 and was pronounced dead at 0551. The principal concerns were the delayed ambulance response and hospital offloading delays that reduced available ambulance resources; the inquest concluded that the delay resulted in a missed opportunity to provide medical assistance, although it could not be said that earlier intervention would have prevented her death.

Lachlan Charles Campbell · Prevention of Future Deaths report View report

28 Feb 2025 Cornwall and Isles of Scilly A. Cox

Lachlan Charles Campbell died on 1 November 2022 after being found outside a railway station in a distressed and possibly drug-affected state, where he remained for several hours in heavy rain and cold conditions. The report identifies concerns about delays in ambulance attendance, incomplete information sharing between ambulance and police services, and police officers not providing shelter, warmth, or timely medical attention. The inquest concluded that these failures contributed to his death.

Shaun Mansell · Prevention of Future Deaths report View report

1 Nov 2021 Stoke-on-Trent and North Staffordshire S. Murphy

Shaun Mansell, aged 50, was found deceased at home after an ambulance response to a 999 call was delayed by 8 hours and 15 minutes. The post-mortem cause of death was acute gastrointestinal haemorrhage and liver disease due to chronic alcoholism, but the medical evidence could not determine whether the delay contributed to his death. The principal concerns were excessive ambulance handover delays at hospital and a welfare call during the delay that involved no direct contact with Shaun and was conducted by a paramedic without prior training for such calls.

Andrew Waters · Prevention of Future Deaths report View report

3 Apr 2025 Cornwall and Isles of Scilly G. Davies

Andrew Waters died at Royal Cornwall Hospital on 24 May 2024 after experiencing symptoms of a heart attack and a delay in receiving an ambulance. He went into cardiac arrest shortly after arriving at hospital, and the inquest found that the ambulance delay, attributed to systemic failure across health and social care, possibly denied him potentially lifesaving treatment. The principal concerns were significant ambulance handover delays, emergency department crowding, and insufficient social care provision affecting patient flow.

Bernhard John Marek · Prevention of Future Deaths report View report

19 Jul 2023 Manchester South A. Mutch

Bernhard John Marek sustained an accidental fall, suffered a fractured neck of femur, and died in hospital on 6 January 2023 after developing pneumonia. Concerns included prolonged ambulance waits for frail elderly patients with hip fractures and delays in ambulances offloading patients at emergency departments.

Diana FAIRWEATHER-PURKIS · Prevention of Future Deaths report View report

17 Feb 2025 Teesside and Hartlepool P. Appleton

Diana Fairweather-Purkis waited 9 hours and 56 minutes for an ambulance after calling the 111 Service, was admitted to hospital, and died on 3 October 2022 due to multi-organ failure secondary to urosepsis. The report identifies insufficient ambulance availability, delays in releasing ambulance crews after hospital attendance because of patient handover delays, and delays in prescribing and administering antibiotics as substantive concerns or contributing factors.

Peter Scott · Prevention of Future Deaths report View report

26 May 2016 Nottinghamshire H. Connor

Peter Scott suffered an aortic dissection at home on 3 December 2015 and experienced a substantial delay in ambulance attendance after a call was prioritised as Green 2. The principal concern was that resource shortages, frequent use of Capacity Management Plans, recruitment problems and delayed hospital handovers posed a serious risk to the public and could contribute to future deaths.

Christina Avis RUSE · Prevention of Future Deaths report View report

26 Aug 2022 Norfolk J. Lake

Christina Avis RUSE underwent a total left hip replacement on 14 December 2021, deteriorated, and died on 15 December 2021 after transfer to hospital was required. The report raises concern about delays in ambulance availability and response during high demand, noting that future deaths may occur while measures to address the issue are assessed.

Stuart Knight · Prevention of Future Deaths report View report

22 Sep 2015 Central Lincolnshire S. Fisher

Stuart Knight was found unconscious in a road in Wainfleet after apparently falling backwards and hitting his head. There were delays in the arrival of ambulance services, including 1 hour and 24 minutes between the first call and the arrival of the double-crewed ambulance; the report identified these delays as significant and unacceptable. Mr Knight was taken to hospital and died later that day, following a head injury with haemorrhage and skull fracture, with alcohol excess also recorded as a medical cause.

Daphne Edith Williams · Prevention of Future Deaths report View report

25 May 2017 North Wales (East and Central) J. Gittins

Daphne Edith Williams fell outside her home on 23 September 2016 and sustained a fractured hip. An ambulance response took more than six hours, during which she remained on a concrete path; the report raised concerns about ambulance delays, emergency department admission, resource availability and patient flow, while stating that the delay could not be said to have contributed to her death.

Peter Parker · Prevention of Future Deaths report View report

22 Oct 2024 Swansea and Neath Port Talbot A. Gruffydd

Peter Parker sustained a laceration to his right wrist from broken glass at home and called an ambulance, but the call disconnected and assistance arrived approximately 9½ hours later, after he had died. The principal concern was that the ambulance response exceeded the expected survival time for the injury, with delays attributed to ambulances waiting to hand over patients at emergency departments.

Kevin George Woods · Prevention of Future Deaths report View report

3 Oct 2024 Cornwall and Isles of Scilly G. Davies

Kevin George Woods died on 17 January 2024 after suffering cardiac arrest following a prolonged ambulance delay when no Category 2 ambulance was available. The inquest found that he had an undiagnosed and possibly treatable heart condition and that the delay denied him potentially lifesaving treatment. The principal concerns were continuing ambulance and hospital handover delays, inadequate social care and community healthcare provision contributing to delayed discharges, and the absence of a single organisation responsible for managing the associated patient-safety risks.

Margaret Megan Evans · Prevention of Future Deaths report View report

26 Jun 2018 North Wales (East and Central) J. Gittins

Margaret Megan Evans fell outside her home on 22 January 2018 and sustained a fractured hip. Delays in ambulance attendance, admission to the emergency department and being seen by an ED doctor left her lying on a concrete path for more than three hours and delayed medical assessment; the report states that it cannot be said these delays contributed to her death, which was recorded as accidental with hospital-acquired pneumonia and a fractured neck of femur.

Matthew Luke FAULKNER · Prevention of Future Deaths report View report

29 Mar 2018 Hertfordshire G. Sullivan

Matthew Faulkner was found hanging from his bathroom door handle on the evening of 30 May 2017 and was confirmed dead at 21:57. The report raised concerns about the almost five-hour delay between the emergency call and ambulance attendance, as well as ambulance service demand exceeding available resources and delays handing patients over to hospital.

DENNIS RICHARD HARRY · Prevention of Future Deaths report View report

22 Sep 2024 Cornwall and Isles of Scilly G. Davies

Dennis Richard Harry died at Royal Cornwall Hospital on 10 January 2023 from heart disease and Covid-19 infection following an 18-hour-and-50-minute ambulance delay, including delays in response and hospital handover. The report identified systemic concerns about inadequate social care, community hospital provision and primary healthcare support contributing to delayed discharges, ambulance delays and emergency department crowding. It also identified no single organisation with responsibility for ensuring sufficient social care provision or overseeing patient safety risks from ambulance delays.

Philip Gordon Ross · Prevention of Future Deaths report View report

16 Sep 2024 Surrey S. Ridge

Philip Gordon Ross suffered a fall at home on 3 December 2023 and was unable to move while awaiting an ambulance. His ambulance call was not clinically validated or re-triaged promptly, and the ambulance arrived at around 02:30 hours after his condition had deteriorated. He later died in hospital on 19 December 2023 from multiple organ failure caused by rhabdomyolysis and bronchopneumonia precipitated by the fall. The principal concern was that late re-triage or clinical validation of Category 3 and 4 ambulance calls may place patients at risk of early death.

Raymond Henry Davidson (Raymond) · Prevention of Future Deaths report View report

27 Feb 2018 Sunderland D. Winter

Raymond Henry Davidson died at home on 10 June 2017 after ambulance responses to urgent and emergency calls did not attend before he stopped breathing. The report identified ongoing ambulance resource shortages and delays in responding to urgent cases, as well as concerns that the initial clinical review was not sufficiently robust because telephone contact was not made directly with Raymond.

John Charles Seagrove and 2 others · Prevention of Future Deaths report View report

23 Nov 2023 Cornwall and Isles of Scilly A. Cox

The report concerns the deaths of John Charles Seagrove, Pauline Mary Humphris and Patricia Joan Steggles, following delays in emergency ambulance response and in handing patients over to hospital staff. The report raises concerns about worsening emergency department pressures, with ambulances waiting outside, and reported burnout and recruitment difficulties among healthcare staff. In Mrs Humphris’s case, the coroner found that ambulance and hospital admission delays may have contributed to the outcome; in Mrs Steggles’s case, the inquest heard that earlier hospital arrival would probably have led to survival.